Application Form

Patient Centered Medical Care Inc.

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name

*

Address 1

*

Last Name

*

Address 2

City

*

State

Home Phone

*

Zip

*

Work Phone

Driver's License Number

Mobile Phone

Email

*

Section 1 - General Information

Number

Question

Effective Date

Expiration Date

1.

Date Available?

2.

Position Applied For?

Temporary/Per Diem

Regular Full Time

Regular Part Time

Work weekends

Work evenings

3.

Desired Salary

4.

Social Security Number

5.

How did you hear about PCMC Inc.(required)

6.

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other?(required)

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by me are true and correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this application or any document used to secure this position can be grounds for refection of application or , if am employed by PCMC Inc., terms for my immediate termination from the company.

I understand that if I am employed, my employment is not definite and can be terminated at any time either with or without prior notice, by either me or PCMC Inc.

I permit the company to examaine my references, record of employment, education record, and any other information I have provided. I authorize the references I have listed to disclose any information related to my work record and my professional expereinces with them, without giving me prior notice of such disclosure. In addition, I release PCMC Inc., my former employers and all otehr persons, corporations partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such examination or revelation.